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The Long-Term Care Standards ProjectPressure injuries, falls, staffing, and the record — sourced to primary authority.

The federal staffing floor is gone. The standard of care is not.

42 CFR Part 483, the surveyor guidance underneath it, the federal claim and survey data, and the controlling case law — mapped for the attorney who has to prove or disprove that harm to a resident was avoidable. Written to be equally usable by a family's counsel and a facility's counsel.

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Published byVident Partners — expert witness referral, since 2005

Anchored byAl Vangura Jr., M.S., CPSI · Nicholas A. Alfonso, M.D.

References41 primary sources, every URL checked

The Long-Term Care Standards Project is an independent reference on what federal law, state licensure, and recognized clinical practice actually require of a nursing home, assisted living residence, or memory care community before, during, and after harm to a resident — pressure injuries, falls and elopement, malnutrition and dehydration, sepsis, medication error, abuse and neglect, and the staffing and ownership questions underneath all of them. It is written to be equally usable by the family's counsel and the facility's counsel, because a standard only one side trusts is not a standard.

Where this stands

The regulatory floor moved down. The duty did not.

About 1.2 million people live in the 14,700 nursing homes in the United States on a given day, across 1.6 million licensed beds, and 72.4 percent of those facilities are for-profit. The easy story about them is that abuse is exploding. The data does not support that story, and an expert who leads with it gets dismantled. Antipsychotic use among long-stay residents fell 40.6 percent between the fourth quarter of 2011 and the second quarter of 2025 — from 23.9 percent to 14.2 percent — on CMS's own quality measure. A 2023 systematic review and meta-analysis of eighteen prospective nursing home studies found that fall incidence generally decreased from 1998 to 2021. And the most consequential regulatory event of the last two years ran the other way entirely: the federal minimum staffing standard was vacated by two district courts, suspended by statute until September 30, 2034, and formally repealed by CMS effective February 2, 2026.

What actually changed, and what did not

The true story is harder and considerably more useful. The regulatory floor moved down; the duty did not. The Nursing Home Reform Act still requires a facility to provide services that attain or maintain “the highest practicable physical, mental, and psychosocial well-being of each resident,” and every quality-of-care requirement in 42 CFR Part 483 stands untouched. Exposure keeps climbing regardless: in CNA's study of aging services liability claims closed between January 1, 2021 and December 31, 2023, resident falls and pressure injuries alone accounted for 63.2 percent of closed claims, and the average total incurred on a resident abuse claim in skilled nursing rose 45.7 percent, to $375,338. The record on which those claims are tried is also less reliable than it looks: in September 2025 HHS-OIG reported that facilities failed to report 43 percent of falls with major injury and hospitalization in required resident assessments, and that the facilities publishing the lowest fall rates were the least likely to have reported them.

CMS wrote the test itself

What actually decides these matters is narrower than the rhetoric on either side, and CMS wrote the test itself. In the surveyor guidance for pressure injuries, a harm is “avoidable” if the facility failed to evaluate the resident's clinical condition and risk factors, define and implement interventions consistent with professional standards of practice, monitor and evaluate their impact, or revise them as appropriate — and “unavoidable” if it did all four. Assess, plan, implement, revise. That same four-verb structure governs decline in activities of daily living, loss of range of motion, and nutritional status, each carrying its own express exception for what the resident's clinical condition made inevitable. Half the answers that test produces favor the facility. That is why it is worth publishing plainly.

How the injury happened, and what it cost

This Center is anchored by two Vident Partners experts who answer the half of these cases that nursing testimony is least equipped to reach. Al Vangura Jr., M.S., CPSI, is a forensic biomechanist with an M.S. in Bioengineering from the University of Pittsburgh and nearly forty years in product design, development, and testing — including twenty-five in medical devices — retained on more than 400 cases split evenly between plaintiff and defense and qualified to testify twenty-nine times across thirteen states on injury mechanism, fall analysis, assistive and patient-handling equipment, and warnings. Nicholas A. Alfonso, M.D., is a fellowship-trained orthopedic trauma surgeon and Assistant Professor of Orthopedics at the University of Colorado Anschutz School of Medicine, with more than twenty-six peer-reviewed publications on fracture fixation, limb salvage, and fracture-related infection — the clinical endpoint of both the hip fracture after a fall and the osteomyelitis under a Stage 4 sacral wound. Whether the event described can produce the injury found, and what that injury then required, are the two questions that most often decide the number.

The scale

What the record shows

Each figure below is reported with the source that produced it and the period it covers. Numbers describing a population are not findings about any individual case.

14,700

nursing homes in the United States in 2022, holding 1.6 million licensed beds and roughly 1.2 million residents on a given day, per the National Center for Health Statistics. 72.4 percent are for-profit. These are the biennial National Post-acute and Long-term Care Study figures and cover certified nursing homes only — assisted living and memory care are counted separately and are regulated by state licensure rather than by 42 CFR Part 483.^{[30, 31]}

No federal floor

The May 2024 minimum staffing rule — 0.55 RN, 2.45 nurse aide, and 3.48 total nurse staffing hours per resident day, plus a 24/7 onsite RN — was vacated at summary judgment by two district courts, suspended by section 71111 of Public Law 119-21 until September 30, 2034, and repealed by CMS at 90 FR 55687 effective February 2, 2026. There is currently no federal numeric staffing minimum for long-term care facilities.^{[11, 12, 13]}

63.2%

of closed aging services professional liability claims were resident falls and pressure injuries, in CNA's 12th-edition claim study of claims closed January 1, 2021 through December 31, 2023 (indemnity payments under $10,000 excluded). Overall average total incurred rose 3.8 percent to $259,443; resident abuse claims in skilled nursing rose 45.7 percent to $375,338; elopement averaged $303,883 and medication error $306,373. CNA cautions that the dataset spans the pandemic era and should not be used to project future trends.^[32]

43%

of falls with major injury and hospitalization among Medicare-enrolled nursing home residents were not reported in required resident assessments between July 2022 and June 2023, per HHS-OIG report OEI-05-24-00180, issued September 11, 2025. OIG found that “nursing homes with the lowest fall rates on Care Compare were the least likely to report the falls we examined.” An earlier OIG study of August 2011 discharges found that 33 percent of Medicare skilled nursing residents experienced an adverse event or temporary harm within 35 days, and that physician reviewers judged 59 percent of those events preventable.^{[28, 29]}

23.9% → 14.2%

antipsychotic use among long-stay nursing home residents, fourth quarter 2011 to second quarter 2025 — a 40.6 percent decline on CMS's own MDS-based quality measure, which excludes residents diagnosed with schizophrenia, Huntington's disease, or Tourette syndrome. CMS states plainly that clinical indications for these medications exist and that it “does not expect that the national prevalence of antipsychotic medication use will decrease to zero.”^[27]

128% / 94%

mean and median annual nursing staff turnover, calculated from 492 million payroll-verified nurse shifts across 15,645 facilities (Health Affairs, 2021). CMS now publishes a turnover measure of its own from Payroll-Based Journal data, and the daily staffing file for the specific dates in a case is public and downloadable — which makes actual staffing on the shift at issue a matter of record rather than argument.^{[26, 33]}

The standards

What the law and the record actually require

Eleven questions that decide long-term care matters, answered from the controlling authority and the surveyor guidance underneath it. Every assertion carries a numbered citation to the source.

The duty: “highest practicable”

The Nursing Home Reform Act of 1987 is codified for Medicare at 42 U.S.C. § 1395i-3 and for Medicaid at § 1396r. It requires a facility to “provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with a written plan of care.” The regulations restate the principle twice. Section 483.24 makes quality of life “a fundamental principle that applies to all care and services provided to facility residents.” Section 483.25 does the same for quality of care and requires that residents “receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices.” Read that last clause carefully: it imports the outside clinical standard into the federal requirement, and it makes the facility's own care plan a measure of the facility's own conduct.^{[1, 2, 3, 4, 5]}

Avoidable and unavoidable: the four questions CMS actually asks

CMS defines both words in Appendix PP, the surveyor guidance to Part 483. “Avoidable” means the resident developed a pressure ulcer or injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. “Unavoidable” means the resident developed one even though the facility did all four. That is a four-question test, and it is not confined to skin. Section 483.24(a) uses the identical construction for decline in activities of daily living “unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable,” § 483.25(c) uses it for range of motion, and § 483.25(g)(1) uses a parallel clause for nutritional status. Most long-term care matters are decided inside those four verbs.^{[3, 4, 7]}

The remaining 9 standards

Pressure injuries: a stage describes tissue, not time
Falls, supervision, and a hole in the data
Nutrition, hydration, and what comes after
Staffing in 2026: date it, do not assume it
Abuse, neglect, and the two-hour clock
Medication errors: the five percent rule and the significant error
Arbitration in the admission agreement
What a deficiency and a star rating actually are
Ownership, and the section 1983 question

Read the full standards →

A one-star rating is not a finding about care. It means the bottom twenty percent of that state — and by construction, every state has one.

Where it comes up

Matters that turn on these standards

Pressure injury and wound claims — avoidability, staging, offloading, nutrition, and reassessment — for a resident's family and for the facility alike
Fall and fall-injury claims: risk assessment, intervention selection, supervision, and whether the mechanism described can produce the fracture actually found
Elopement and unsafe wandering, including alarm reliance, egress control, wander-risk assessment, and the adequacy of the post-elopement response
Malnutrition, dehydration, unplanned weight loss, and disputes over enteral feeding, therapeutic diets, and honoring a resident's refusal
Sepsis, urinary tract infection, and pneumonia claims turning on failure to recognize, escalate, or transfer — and on whether transfer would have changed the outcome
Medication error, polypharmacy, and chemical restraint matters, including antipsychotic prescribing without a documented clinical indication
Resident-on-resident altercation and staff-on-resident abuse claims: hiring, registry and background screening, supervision, investigation, and section 1150B reporting timelines
Wrongful death and survival actions arising from any of the above, and the damages proof peculiar to a plaintiff with a limited remaining life expectancy
Understaffing and corporate or institutional negligence claims — the facility assessment, budget and census, agency-staff reliance, and ownership structure
Motions to compel arbitration under an admission-agreement clause: the signer's authority, the 30-day rescission right, capacity, and unconscionability
Regulatory and enforcement matters — immediate jeopardy citations, civil money penalties, denial of payment for new admissions, informal dispute resolution, and termination
Assisted living and memory care claims, where 42 CFR Part 483 does not apply and the governing standard is state licensure plus the community's own written policies

The bar

What to require of an expert in these matters

The same standard applies to the experts who anchor this Center. It is published so counsel can hold anyone — including us — to it.

Operating experience inside a long-term care facility at the level in dispute — a director of nursing, administrator, or medical director who has actually signed the assessments, care plans, and plans of correction at issue, not only studied them.
Current or recent practice in the setting. Acuity rose, lengths of stay fell, and agency staffing spread between 2015 and 2026. An opinion built on the nursing home of a decade ago is an opinion about a different building.
The discipline to name which standard governs. Federal Part 483 requirements, state licensure regulations, the facility's own written policies, and general professional nursing standards are four distinct sources that do not always agree. An expert who blurs them will not survive cross-examination.
Wound credentialing where skin is the issue — a certified wound care clinician who can stage from serial photographs and measurements, explain why a deep tissue injury declares itself when it does, and concede that unavoidable injuries exist, because CMS says they do.
A separate expert for mechanism and for treatment. Whether a described fall can produce the fracture found is a biomechanics question; whether that fracture was then managed to standard is an orthopedic one. Neither is a nursing question, and asking one witness to carry all three is how sound cases come apart.
A records-first methodology stated in writing before any opinion is formed: the MDS assessments, the care plan and every revision to it, treatment and medication administration records, weight and intake logs, wound measurements and photographs, incident reports, nurse and aide assignment sheets, and the payroll-based staffing data for the actual days in question.
A documented testimony history on both sides of the “v.”, with prior Daubert and Frye challenges and their outcomes disclosed. In a field this thick with repeat plaintiff and repeat defense witnesses, an expert retained only ever by one side is an exhibit for the other.
Willingness to write the concession into the report. Rule 702(d) requires that an opinion “reflects a reliable application of the principles and methods to the facts of the case.” An expert who cannot identify which harms in a given record were unavoidable has not applied CMS's own method.

Anchor experts

How the injury happened, and what the injury cost.

Al Vangura Jr., M.S., CPSIForensic Biomechanics Expert · University of Pittsburgh (Bioengineering)

M.S. Bioengineering, Pitt · B.S. Biomechanics, Penn State · CPSI Certified

A forensic biomechanics specialist with nearly 40 years of product development experience, 400+ cases retained, and testimony accepted in 13 states across county, state, and federal courts. Key expert in a $19 million jury verdict.

Injury causation and mechanismSlip, trip and fall analysisProduct liability and defectMotor vehicle accident reconstructionFull profile, publications and testimony history →

Nicholas A. Alfonso, M.D.Assistant Professor of Orthopedics, University of Colorado Anschutz School of Medicine

M.D. · Board-Certified Orthopedic Trauma · Fellowship-Trained · AOTrauma Faculty

A fellowship-trained orthopedic trauma surgeon at the University of Colorado with 26+ peer-reviewed publications. Board-certified in orthopedic trauma, specializing in pelvic and acetabular fractures, bone infections, and limb salvage procedures.

Orthopedic trauma surgeryPelvic and acetabular fracturesFracture-related infectionsLimb salvage proceduresFull profile, publications and testimony history →

Profiles, publication lists, and testimony histories are maintained on each expert’s Vident Partners page. Appearing here is not an endorsement of any opinion an expert may offer in a particular matter.

In the directory

Related expert witness specialties

These specialty pages live in the Vident Partners expert directory. This Center does not duplicate them.

Medical & Healthcare

Nursing Home & Long-Term Care

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Nursing Standards

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Medical & Healthcare

Geriatric Medicine

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Medical & Healthcare

Legal Nurse Consultant

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Medical & Healthcare

Life Care Planning

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Medical & Healthcare

Infectious Diseases

Expert directory →

Writing

Published, and in preparation

Already published in Vident Partners Insights.

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Marty Aisenberg · November 28, 2023

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Hospital institutional liability for the negligence of contract physicians.

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Kentucky Supreme Court reemphasizes the requirement of expert testimony on causation in medical malpractice cases; res ipsa doesn’t apply to causation unless it also applies to negligence.

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Planned for this Center. These are commissioned outlines, not published pages — there is nothing to read yet, and we would rather say so than link you somewhere that does not exist.

Not yet published

Primer

Avoidable, Unavoidable, and the Four Questions CMS Actually Asks

The F686 test, verbatim — and why the same four verbs govern weight loss, range of motion, and ADL decline just as much as skin.

Not yet published

The Data

Forty-Three Percent: What the OIG Found About Nursing Home Fall Reporting

The 2025 federal audit that turned a public quality measure into a reporting artifact, and what it does to MDS-based proof on both sides.

Not yet published

Staffing

There Is No Federal Staffing Minimum. Here Is What There Is.

Vacated twice, suspended to 2034, then repealed — and the facility assessment that quietly became the operative number.

Not yet published

For the Defense

Reading a Survey Deficiency the Way the Surveyor Wrote It

Scope and severity, the sample, the plan of correction, and the difference between a certification finding and the standard of care.

Not yet published

Damages

Proving Damages for a Resident With Two Years to Live

Life expectancy, pain and suffering, statutory elder-abuse remedies, and the arithmetic both sides are actually arguing about.

Questions counsel ask

Answers, with the citation attached

Does a pressure injury mean the facility was negligent?

No. The regulation itself says a resident “does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable,” and CMS defines unavoidable as the facility having evaluated the resident's condition and risk factors, defined and implemented interventions consistent with professional standards, monitored and evaluated their impact, and revised them as appropriate. The dispute is almost never whether the wound exists. It is whether those four things happened, and the record either shows them or it does not.^{[4, 7]}

Is there a federal minimum staffing ratio we can measure the facility against?

Not as of 2026. The 2024 rule's 0.55, 2.45, and 3.48 hours per resident day and its 24/7 registered nurse requirement were vacated by two district courts, suspended by statute until September 30, 2034, and repealed by CMS effective February 2, 2026. What binds is § 483.35 — sufficient staff with appropriate competencies, licensed nurses on a 24-hour basis, an RN for at least 8 consecutive hours a day 7 days a week, and a full-time director of nursing — measured against the facility's own § 483.71 assessment of what it determined it needed. The payroll-based staffing file for the specific dates is public and is usually more probative than any ratio.^{[9, 10, 11, 12, 13, 26]}

The facility is rated one star. Isn't that proof of substandard care?

No, and arguing it invites a damaging cross-examination. CMS rates the health inspection domain on relative performance within a state: the top 10 percent receive five stars, the middle 70 percent receive two to four stars in roughly equal thirds, and “the bottom 20 percent receive a one-star rating.” Every state produces a bottom 20 percent regardless of the absolute quality of its facilities. A rating is a screening tool for where to look. It is not a finding about the care a particular resident received.^[22]

Can we bring the federal nursing home rights under 42 U.S.C. § 1983?

Sometimes. In Health and Hospital Corporation of Marion County v. Talevski (2023) the Court held 7-2 that the Nursing Home Reform Act's unnecessary-restraint and predischarge-notice provisions “unambiguously confer individual federal rights enforceable under § 1983.” But § 1983 requires action under color of state law, and the facility in Talevski was county-owned. With 72.4 percent of nursing homes in for-profit ownership, most defendants are not state actors, and for them the claim remains state-law negligence with the federal requirements offered, if at all, as evidence of the standard.^{[21, 30]}

The family signed an arbitration clause at admission. Is it enforceable?

Usually the fight is not about arbitration itself. Pre-dispute binding arbitration agreements have been permitted since the 2019 final rule, and the Supreme Court has struck down state rules singling them out — Marmet (2012) and Kindred (2017). What remains are the conditions CMS imposed at 42 CFR § 483.70(m): it could not be required as a condition of admission or continued care, it had to be explained in a form and language the signer understood, and it had to grant a right to rescind within 30 calendar days of signing. Ordinary contract defenses also survive, and whether the signer actually held authority to bind the resident is the question that decides most of these motions.^{[17, 18, 19, 20]}

Which expert do we actually need?

Usually more than one, scoped so they do not overlap. A nursing or administration expert establishes what the facility's assessment, care plan, and policies required and whether staff delivered them. A geriatrician or medical director addresses clinical judgment, prognosis, and whether a decline was the disease or the care. A wound clinician addresses staging and avoidability. A biomechanist addresses whether the event described can produce the injury found, and an orthopedic surgeon addresses how that injury was then managed and what it cost. Asking one witness to carry all of it is the most common avoidable error in these cases.^[41]

References

Every figure in this Center, traced to its source

41 primary sources

Each URL was checked before publication and is rechecked whenever a page in The Long-Term Care Standards Project is revised. The numbered markers throughout this Center link straight to the entry they rest on.

View the full reference list →

Working a long-term care matter?

Tell us the question at issue and we will identify qualified experts — for a resident's family and for a facility alike. The consultation is complimentary and carries no obligation. Requests made here are tagged to The Long-Term Care Standards Project.

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